|
RHOGAM 300 MCG INJ PFS
|
Facility
|
OP
|
$751.00
|
|
|
Service Code
|
CPT J2790
|
| Hospital Charge Code |
3303035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.84 |
| Max. Negotiated Rate |
$713.45 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$182.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$450.60
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$182.61
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$144.66
|
| Rate for Payer: Cash Price |
$450.60
|
| Rate for Payer: Cash Price |
$450.60
|
| Rate for Payer: Cigna Commercial |
$638.35
|
| Rate for Payer: First Health Commercial |
$675.90
|
| Rate for Payer: First Health Workers Compensation |
$289.96
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$675.90
|
| Rate for Payer: GEHA Commercial |
$90.84
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$675.90
|
| Rate for Payer: Humana ChoiceCare |
$195.26
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$147.61
|
| Rate for Payer: Multiplan All |
$683.41
|
| Rate for Payer: New Mexico Health Connections Medicare |
$450.60
|
| Rate for Payer: OMNI Networks Commercial |
$525.70
|
| Rate for Payer: One Health Plan PPO/POS |
$675.90
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$170.44
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$147.61
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$713.45
|
| Rate for Payer: Three Rivers Provider Network All |
$563.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$660.88
|
| Rate for Payer: United Healthcare Managed Medicaid |
$147.61
|
| Rate for Payer: United Payors & United Providers UP&UP |
$698.43
|
| Rate for Payer: Zelis Auto |
$300.40
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$375.50
|
| Rate for Payer: Zelis Worker's Compensation |
$205.02
|
|
|
rh REF006064
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
22990748
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$88.35 |
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$79.05
|
| Rate for Payer: First Health Commercial |
$83.70
|
| Rate for Payer: First Health Workers Compensation |
$6.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$83.70
|
| Rate for Payer: GEHA Commercial |
$65.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$83.70
|
| Rate for Payer: Multiplan All |
$84.63
|
| Rate for Payer: OMNI Networks Commercial |
$65.10
|
| Rate for Payer: One Health Plan PPO/POS |
$83.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$88.35
|
| Rate for Payer: Three Rivers Provider Network All |
$69.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$86.49
|
| Rate for Payer: Zelis Auto |
$37.20
|
| Rate for Payer: Zelis Worker's Compensation |
$4.68
|
|
|
rh REF006064
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
22990748
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$88.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$5.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$55.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$5.38
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$37.27
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$79.05
|
| Rate for Payer: First Health Commercial |
$83.70
|
| Rate for Payer: First Health Workers Compensation |
$6.62
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$83.70
|
| Rate for Payer: GEHA Commercial |
$74.40
|
| Rate for Payer: GEHA Medicare |
$37.27
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$83.70
|
| Rate for Payer: Humana ChoiceCare |
$41.00
|
| Rate for Payer: Humana Medicare Advantage |
$37.27
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$62.61
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$4.35
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$37.27
|
| Rate for Payer: Multiplan All |
$84.63
|
| Rate for Payer: New Mexico Health Connections Medicare |
$63.36
|
| Rate for Payer: OMNI Networks Commercial |
$65.10
|
| Rate for Payer: One Health Plan PPO/POS |
$83.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$5.03
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$4.35
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$37.27
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$88.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$74.54
|
| Rate for Payer: Three Rivers Provider Network All |
$69.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$36.52
|
| Rate for Payer: United Healthcare Commercial |
$79.05
|
| Rate for Payer: United Healthcare Managed Medicaid |
$4.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.27
|
| Rate for Payer: United Payors & United Providers UP&UP |
$86.49
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$37.27
|
| Rate for Payer: Zelis Auto |
$37.20
|
| Rate for Payer: Zelis Medicare |
$31.68
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$44.72
|
| Rate for Payer: Zelis Worker's Compensation |
$4.68
|
|
|
RHYTHM STRIP
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
4000030
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$152.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
RHYTHM STRIP
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
4000030
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$47.94 |
| Max. Negotiated Rate |
$207.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$130.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$78.53
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$62.21
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$56.40
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cigna Commercial |
$185.30
|
| Rate for Payer: First Health Commercial |
$196.20
|
| Rate for Payer: First Health Workers Compensation |
$84.17
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$196.20
|
| Rate for Payer: GEHA Commercial |
$174.40
|
| Rate for Payer: GEHA Medicare |
$56.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$196.20
|
| Rate for Payer: Humana ChoiceCare |
$62.04
|
| Rate for Payer: Humana Medicare Advantage |
$56.40
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$94.75
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$63.47
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$56.40
|
| Rate for Payer: Multiplan All |
$198.38
|
| Rate for Payer: New Mexico Health Connections Medicare |
$95.88
|
| Rate for Payer: OMNI Networks Commercial |
$152.60
|
| Rate for Payer: One Health Plan PPO/POS |
$196.20
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$73.29
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$63.47
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$56.40
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$207.10
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$112.80
|
| Rate for Payer: Three Rivers Provider Network All |
$163.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$55.27
|
| Rate for Payer: United Healthcare Commercial |
$185.30
|
| Rate for Payer: United Healthcare Managed Medicaid |
$63.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.40
|
| Rate for Payer: United Payors & United Providers UP&UP |
$202.74
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$56.40
|
| Rate for Payer: Zelis Auto |
$87.20
|
| Rate for Payer: Zelis Medicare |
$47.94
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$67.68
|
| Rate for Payer: Zelis Worker's Compensation |
$59.51
|
|
|
RIFAMPIN CAP 150MG
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 68180065806
|
| Hospital Charge Code |
3300792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$11.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$3.64
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: New Mexico Health Connections Medicare |
$8.40
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$12.32
|
| Rate for Payer: United Healthcare Managed Medicaid |
$3.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$7.00
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
RIFAMPIN CAP 150MG
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68180065806
|
| Hospital Charge Code |
3300792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$11.90
|
| Rate for Payer: First Health Commercial |
$12.60
|
| Rate for Payer: First Health Workers Compensation |
$5.41
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$12.60
|
| Rate for Payer: GEHA Commercial |
$9.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$12.60
|
| Rate for Payer: Multiplan All |
$12.74
|
| Rate for Payer: OMNI Networks Commercial |
$9.80
|
| Rate for Payer: One Health Plan PPO/POS |
$12.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$13.30
|
| Rate for Payer: Three Rivers Provider Network All |
$10.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$13.02
|
| Rate for Payer: Zelis Auto |
$5.60
|
| Rate for Payer: Zelis Worker's Compensation |
$3.82
|
|
|
RIFAMPIN CAP 300MG
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 68180065906
|
| Hospital Charge Code |
3300793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$26.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
RIFAMPIN CAP 300MG
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 68180065906
|
| Hospital Charge Code |
3300793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: First Health Commercial |
$34.20
|
| Rate for Payer: First Health Workers Compensation |
$14.67
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$34.20
|
| Rate for Payer: GEHA Commercial |
$30.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$34.20
|
| Rate for Payer: Humana ChoiceCare |
$9.88
|
| Rate for Payer: Multiplan All |
$34.58
|
| Rate for Payer: New Mexico Health Connections Medicare |
$22.80
|
| Rate for Payer: OMNI Networks Commercial |
$26.60
|
| Rate for Payer: One Health Plan PPO/POS |
$34.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$36.10
|
| Rate for Payer: Three Rivers Provider Network All |
$28.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$33.44
|
| Rate for Payer: United Healthcare Managed Medicaid |
$9.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$35.34
|
| Rate for Payer: Zelis Auto |
$15.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$19.00
|
| Rate for Payer: Zelis Worker's Compensation |
$10.37
|
|
|
RIFAXIMIN 550MG TAB
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
NDC 65649030302
|
| Hospital Charge Code |
3305003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$340.00
|
| Rate for Payer: First Health Commercial |
$360.00
|
| Rate for Payer: First Health Workers Compensation |
$154.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$360.00
|
| Rate for Payer: GEHA Commercial |
$280.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$360.00
|
| Rate for Payer: Multiplan All |
$364.00
|
| Rate for Payer: OMNI Networks Commercial |
$280.00
|
| Rate for Payer: One Health Plan PPO/POS |
$360.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$380.00
|
| Rate for Payer: Three Rivers Provider Network All |
$300.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$372.00
|
| Rate for Payer: Zelis Auto |
$160.00
|
| Rate for Payer: Zelis Worker's Compensation |
$109.20
|
|
|
RIFAXIMIN 550MG TAB
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
NDC 65649030302
|
| Hospital Charge Code |
3305003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$340.00
|
| Rate for Payer: First Health Commercial |
$360.00
|
| Rate for Payer: First Health Workers Compensation |
$154.44
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$360.00
|
| Rate for Payer: GEHA Commercial |
$320.00
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$360.00
|
| Rate for Payer: Humana ChoiceCare |
$104.00
|
| Rate for Payer: Multiplan All |
$364.00
|
| Rate for Payer: New Mexico Health Connections Medicare |
$240.00
|
| Rate for Payer: OMNI Networks Commercial |
$280.00
|
| Rate for Payer: One Health Plan PPO/POS |
$360.00
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$380.00
|
| Rate for Payer: Three Rivers Provider Network All |
$300.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$352.00
|
| Rate for Payer: United Healthcare Managed Medicaid |
$100.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$372.00
|
| Rate for Payer: Zelis Auto |
$160.00
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$200.00
|
| Rate for Payer: Zelis Worker's Compensation |
$109.20
|
|
|
RisperiDONE 0.25MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904635761
|
| Hospital Charge Code |
3300797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
RisperiDONE 0.25MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904635761
|
| Hospital Charge Code |
3300797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
RisperiDONE 0.5MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904736161
|
| Hospital Charge Code |
3300798
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
RisperiDONE 0.5MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904736161
|
| Hospital Charge Code |
3300798
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
risperiDONE 1MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 50458059601
|
| Hospital Charge Code |
3301768
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$6.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Humana ChoiceCare |
$2.08
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: New Mexico Health Connections Medicare |
$4.80
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.04
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.00
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
risperiDONE 1MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 50458059601
|
| Hospital Charge Code |
3301768
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$6.80
|
| Rate for Payer: First Health Commercial |
$7.20
|
| Rate for Payer: First Health Workers Compensation |
$3.09
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$7.20
|
| Rate for Payer: GEHA Commercial |
$5.60
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$7.20
|
| Rate for Payer: Multiplan All |
$7.28
|
| Rate for Payer: OMNI Networks Commercial |
$5.60
|
| Rate for Payer: One Health Plan PPO/POS |
$7.20
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$7.60
|
| Rate for Payer: Three Rivers Provider Network All |
$6.00
|
| Rate for Payer: United Payors & United Providers UP&UP |
$7.44
|
| Rate for Payer: Zelis Auto |
$3.20
|
| Rate for Payer: Zelis Worker's Compensation |
$2.18
|
|
|
RisperiDONE 1MG TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904635961
|
| Hospital Charge Code |
3301877
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
RisperiDONE 1MG TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904635961
|
| Hospital Charge Code |
3301877
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$2.55
|
| Rate for Payer: First Health Commercial |
$2.70
|
| Rate for Payer: First Health Workers Compensation |
$1.16
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2.70
|
| Rate for Payer: GEHA Commercial |
$2.40
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$0.78
|
| Rate for Payer: Multiplan All |
$2.73
|
| Rate for Payer: New Mexico Health Connections Medicare |
$1.80
|
| Rate for Payer: OMNI Networks Commercial |
$2.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2.85
|
| Rate for Payer: Three Rivers Provider Network All |
$2.25
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$2.64
|
| Rate for Payer: United Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2.79
|
| Rate for Payer: Zelis Auto |
$1.20
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$1.50
|
| Rate for Payer: Zelis Worker's Compensation |
$0.82
|
|
|
risperiDONE CONSTA 37.5MG IM ONLY
|
Facility
|
IP
|
$2,613.00
|
|
|
Service Code
|
CPT J2794
|
| Hospital Charge Code |
3302609
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$713.35 |
| Max. Negotiated Rate |
$2,482.35 |
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cigna Commercial |
$2,221.05
|
| Rate for Payer: First Health Commercial |
$2,351.70
|
| Rate for Payer: First Health Workers Compensation |
$1,008.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,351.70
|
| Rate for Payer: GEHA Commercial |
$1,829.10
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,351.70
|
| Rate for Payer: Multiplan All |
$2,377.83
|
| Rate for Payer: OMNI Networks Commercial |
$1,829.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,351.70
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,482.35
|
| Rate for Payer: Three Rivers Provider Network All |
$1,959.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,430.09
|
| Rate for Payer: Zelis Auto |
$1,045.20
|
| Rate for Payer: Zelis Worker's Compensation |
$713.35
|
|
|
risperiDONE CONSTA 37.5MG IM ONLY
|
Facility
|
OP
|
$2,613.00
|
|
|
Service Code
|
CPT J2794
|
| Hospital Charge Code |
3302609
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$2,482.35 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Advantage HMO |
$9.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$1,567.80
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Preferred |
$9.79
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Managed Medicaid |
$7.76
|
| Rate for Payer: Blue Cross Blue Shield of New Mexico Medicare Advantage |
$10.98
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Cigna Commercial |
$2,221.05
|
| Rate for Payer: First Health Commercial |
$2,351.70
|
| Rate for Payer: First Health Workers Compensation |
$1,008.88
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$2,351.70
|
| Rate for Payer: GEHA Commercial |
$12.08
|
| Rate for Payer: GEHA Medicare |
$10.98
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$2,351.70
|
| Rate for Payer: Humana ChoiceCare |
$12.08
|
| Rate for Payer: Humana Medicare Advantage |
$10.98
|
| Rate for Payer: Molina Healthcare of New Mexico Health Insurance Marketplace |
$18.45
|
| Rate for Payer: Molina Healthcare of New Mexico Medicaid |
$7.92
|
| Rate for Payer: Molina Healthcare of New Mexico Medicare |
$10.98
|
| Rate for Payer: Multiplan All |
$2,377.83
|
| Rate for Payer: New Mexico Health Connections Medicare |
$18.67
|
| Rate for Payer: OMNI Networks Commercial |
$1,829.10
|
| Rate for Payer: One Health Plan PPO/POS |
$2,351.70
|
| Rate for Payer: Presbyterian Health Plan Exchange |
$9.14
|
| Rate for Payer: Presbyterian Health Plan Medicaid |
$7.92
|
| Rate for Payer: Presbyterian Health Plan Medicare HMO/Medicare POS |
$10.98
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$2,482.35
|
| Rate for Payer: Providence Risk & Insurance Services Worker's Compensation |
$21.96
|
| Rate for Payer: Three Rivers Provider Network All |
$1,959.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$10.76
|
| Rate for Payer: United Healthcare Managed Medicaid |
$7.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.98
|
| Rate for Payer: United Payors & United Providers UP&UP |
$2,430.09
|
| Rate for Payer: VistaCare Hospice Medicaid/Medicare |
$10.98
|
| Rate for Payer: Zelis Auto |
$1,045.20
|
| Rate for Payer: Zelis Medicare |
$9.33
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$13.18
|
| Rate for Payer: Zelis Worker's Compensation |
$713.35
|
|
|
RISPERIDONE ODT 2 MG TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 49884040191
|
| Hospital Charge Code |
3302557
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$7.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Humana ChoiceCare |
$2.34
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: New Mexico Health Connections Medicare |
$5.40
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$7.92
|
| Rate for Payer: United Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$4.50
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
RISPERIDONE ODT 2 MG TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 49884040191
|
| Hospital Charge Code |
3302557
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: First Health Commercial |
$8.10
|
| Rate for Payer: First Health Workers Compensation |
$3.47
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$8.10
|
| Rate for Payer: GEHA Commercial |
$6.30
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$8.10
|
| Rate for Payer: Multiplan All |
$8.19
|
| Rate for Payer: OMNI Networks Commercial |
$6.30
|
| Rate for Payer: One Health Plan PPO/POS |
$8.10
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$8.55
|
| Rate for Payer: Three Rivers Provider Network All |
$6.75
|
| Rate for Payer: United Payors & United Providers UP&UP |
$8.37
|
| Rate for Payer: Zelis Auto |
$3.60
|
| Rate for Payer: Zelis Worker's Compensation |
$2.46
|
|
|
risperidone REF716563
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
2299785
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$191.80
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
|
risperidone REF716563
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
2299785
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Blue Cross Blue Shield of New Mexico Blue Community HMO |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cigna Commercial |
$232.90
|
| Rate for Payer: First Health Commercial |
$246.60
|
| Rate for Payer: First Health Workers Compensation |
$27.28
|
| Rate for Payer: Galaxy Health Commercial/Workers Compensation |
$246.60
|
| Rate for Payer: GEHA Commercial |
$219.20
|
| Rate for Payer: Great West Healthcare (Cigna) Commercial |
$246.60
|
| Rate for Payer: Humana ChoiceCare |
$71.24
|
| Rate for Payer: Multiplan All |
$249.34
|
| Rate for Payer: New Mexico Health Connections Medicare |
$164.40
|
| Rate for Payer: OMNI Networks Commercial |
$191.80
|
| Rate for Payer: One Health Plan PPO/POS |
$246.60
|
| Rate for Payer: Providence Risk & Insurance Services Commercial |
$260.30
|
| Rate for Payer: Three Rivers Provider Network All |
$205.50
|
| Rate for Payer: TriWest Veterans Administration/VAPC3 |
$241.12
|
| Rate for Payer: United Healthcare Commercial |
$232.90
|
| Rate for Payer: United Healthcare Managed Medicaid |
$68.50
|
| Rate for Payer: United Payors & United Providers UP&UP |
$254.82
|
| Rate for Payer: Zelis Auto |
$109.60
|
| Rate for Payer: Zelis Primary Direct / Supplemental Network |
$137.00
|
| Rate for Payer: Zelis Worker's Compensation |
$19.29
|
|
